Generalisability and potential deaths averted from intensive blood pressure treatment among the elderly population in the US and China: A nationally representative cross-sectional study

Background The Systolic Blood Pressure Intervention Trial (SPRINT) from the US and the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial from China have consistently demonstrated clinical benefits from intensive blood pressure (BP) treatment among elderly adults with hypertension. However, we have little data on the generalisability and potential implications of a scale-up of intensive BP treatment to all eligible elderly in the US and China. Methods We used two nationally representative data sets from China (Health and Retirement Longitudinal Study (CHALRS), 2011-2012) and the US (National Health and Nutrition Examination Survey (NHANES), 2007-2012) and linked them with CHARLS follow-up data (2013) and the National Death Index (1999-2015), respectively. We estimated the percentage, number, and characteristics of elderly (≥60 years old) meeting the STEP and SPRINT eligibility criteria, and deaths that would be prevented or postponed with the implementation of intensive BP treatment. Results Among the Chinese adults aged 60 years and over, 38.89% (95% confidence interval (CI) = 36.97-40.84) or 85.39 (95% CI = 81.14-89.64) million subjects met the STEP criteria, and 40.90 million (47.90%) adults were not taking antihypertensive medications. In the US, 23.77% (95% CI = 22.32%-25.28) or 12.46 (95% CI = 11.68-13.24) million elderly were eligible for the SPRINT, and 5.78 million (46.36%) were untreated. Overall, 0.07 (95% CI = 0.06-0.08) million deaths in the US and 0.31 (95% CI = 0.25-0.39) in China would be averted annually if intensive BP treatment was implemented, while 120 000 and 680 000 of hypotension cases would be identified yearly in the US and China, respectively. Conclusions A substantial percentage of Chinese and the US elderly meet the eligibility criteria for STEP and SPRINT. If intensive BP treatment was adopted, 70 000 and 310 000 deaths would be prevented or postponed yearly in the US and China, respectively.


Generalizability and potential deaths averted from intensive blood pressure treatment among the elderly population in the US and China: nationally representative cross-sectional study
Online Supplementary Document Table S1 Inclusion and exclusion criteria Table S2 Characteristics of China elderly meeting the STEP and U.S. elderly meeting the SPRINT Table S3 Percentage of China elderly meeting each sequential STEP eligibility criterion  1.An indication for a specific BP lowering medication that the person is not taking.2. Diagnosed secondary hypertension.3.One minute standing SBP < 110 mm Hg. 4. Arm circumference too large or small to allow accurate blood pressure measurement with available devices. 5. History of stroke.6. Cardiovascular event or procedure or hospitalization for unstable angina within last 3 months.7. Symptomatic heart failure within the past 6 months or left ventricular ejection fraction< 35%.8. Diabetes mellitus: a) Taking medications for diabetes at any time in the last 12 months.b) FPG at or above 126 mg/dL, A1C ≥6.5 percent, a two-hour value in an OGTT (2-h PG) at or above 200 mg/dL or a random plasma glucose concentration ≥200 mg/dL.9. Proteinuria in the following ranges (within the past 6 months): a) 24 hour urinary protein excretion ≥ 1 g/day, or b) If measurement a) is not available, then 24 hour urinary albumin excretion ≥ 600 mg/day, or c) If measurements a) or b) are not available, then spot urine protein/creatinine ratio ≥ 1 g/g creatinine, or  11.Glomerulonephritis treated with or likely to be treated with immunosuppressive therapy.12. eGFR < 20 ml/min /1.73m 2 or end-stage renal disease (ESRD).13.A medical condition likely to limit survival to less than 3 years, or a cancer diagnosed and treated within the past 2 years.14.Any factors judged by the clinic team to be likely to limit adherence to interventions.15.Failure to obtain informed consent from participant.16.Currently participating in another clinical trial (intervention study).17.Living in the same household as an already randomized SPRINT participant.18.Any organ transplant.19.Unintentional weight loss > 10% in last 6 months.20.Pregnancy, currently trying to become pregnant, or of child-bearing potential and not using birth control.STEP: Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients; SPRINT: Systolic Blood Pressure Intervention Trial; eGFR: estimated glomerular filtration rate; SBP: systolic blood pressure; CKD: chronic kidney disease; CVD: cardiovascular disease; DBP: diastolic blood pressure; BP: blood pressure; PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; OGTT: oral glucose tolerance test.
d) If measurements a), b), or c) are not available, then spot urine albumin/creatinine ratio≥ 600 mg/g creatinine, or e) If measurements a), b), c), or d) are not available, then urine dipstick ≥ 2+ protein.10. Diagnosis of polycystic kidney disease.

Figure S2 .
Figure S2.Summary statistics and corresponding forest plot for effect of intensive blood pressure treatment on all-cause mortality risk.

Table S4
Percentage of U.S. elderly meeting each sequential SPRINT eligibility criterion Table S5 Potential deaths averted from intensive blood pressure treatment among elderly population in the China and US according to treatment status Figure S1 Number of Chinese adults meeting SPRINT eligibility criteria and U.S. adults meeting STEP eligibility criteria.STEP: Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients; SPRINT: Systolic Blood Pressure Intervention Trial.Figure S2 Summary statistics and corresponding forest plot for effect of intensive blood pressure treatment on all-cause mortality risk.Figure S3 Potential hypotension caused by intensive blood pressure treatment among elderly population in the China and US.

Table S1 .
Inclusion and exclusion criteria

Table S2 .
Characteristics of China elderly meeting the STEP and U.S. elderly meeting the

Table S3 .
Percentage of China elderly meeting each sequential STEP eligibility criterion*

Table S4 .
Percentage of U.S. elderly meeting each sequential SPRINT eligibility criterion* Figure S1.Number of Chinese adults meeting SPRINT eligibility criteria and U.S. adults meeting STEP eligibility criteria.STEP: Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients; SPRINT: Systolic Blood Pressure Intervention Trial.Values are number (95% confidence interval) in millions.SBP: systolic blood pressure; BP: blood pressure.